Provider Demographics
NPI:1659541761
Name:CLYBURN, SHANE CHRISTOPHER (LMP)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:CHRISTOPHER
Last Name:CLYBURN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:SHANE
Other - Middle Name:CHRISTOPHER
Other - Last Name:SHEROD-CLYBURN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:6965 COAL CREEK PKWY SE
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98059-3136
Mailing Address - Country:US
Mailing Address - Phone:425-641-7470
Mailing Address - Fax:425-373-9176
Practice Address - Street 1:6965 COAL CREEK PKWY SE
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WA
Practice Address - Zip Code:98059-3136
Practice Address - Country:US
Practice Address - Phone:425-641-7470
Practice Address - Fax:425-373-9176
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019071225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0229693OtherLABOR AND INDUSTRIES